Prescription Fitness Robert M. Pepper, DO, FAAFP 8 ACOFP 55th Annual Convention & Scientific Seminars
RX: FITNESS Robert M Pepper, DO, FAAFP Assistant Dean for Predoctoral Clinical Education West Virginia School of Osteopathic Medicine rpepper@osteo.wvsom.edu 1
CRF Ability respiratory and circulatory systems to deliver oxygen to working muscles during sustained exercise Maximum Oxygen Consumption VO2 Max (ml) O2 per minute per Kg 2
Maximal intensity VO2 MAX AND CV DISEASE MEN AGE 20-39 40-49 50-59 60+ 20% >50 >47 >42 >37 20% <36 <34 <31 <26 WOMEN AGE 20-39 40-49 50-59 60 20% >41 >38 >34 >31 20% <29 <24 <24 <23 3
Fitness Exercise CRF NON-MODIFIABLE Age Gender Genotype MODIFIABLE Physical Activity Smoking Obesity Cardiopulmonary disease 4
CARDIORESPIRATORY FITNESS MEASURES VO2 Max: maximum amount of O2 that can be utilized during intense sustained exercise CARDIORESPIRATORY FITNESS MEASURES METS Metabolic Equivalent Tasks 5
METABOLIC EQUIVALENT TASKS 1 MET = energy produced average person seated at rest METS AVERAGE WALKING SPEED Walking 3.1 mph 3.4 METS 6
METS x 3.5= VO2 Max <9 9-14 >14 7
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AVOIDING SCA Low vs High CRF 48% SCA 1 MET 14% Cardiorespiratory Fitness and Risk of Sudden Cardiac Death in Men and Women in the United States Mayo Clinic Proceedings, 2016-07-01, Volume 91, Issue 7, Pages 849-857 1913 TRIAL Low aerobic capacity in middle-aged men associated with increased mortality rates during 45 years of follow-up. European Journal Preventive Cardiology, July 2016 9
1913 TRIAL: 792 X 45 YEARS Smoking > VO2max > HTN > Lipids European Journal Preventive Cardiology, July 2016 Esophageal Liver Lung Kidney Gastric Endometrial esophageal adenocarcinoma (HR, 0.58; 95% CI, 0.37-0.89), liver (HR, 0.73; 95% CI, 0.55-0.98), lung (HR, 0.74; 95% CI, 0.71-0.77), kidney (HR, 0.77; 95% CI, 0.70-0.85), gastric cardia (HR, Leukemia Myeloma Bladder Head and Neck Rectal Colon Breast Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults. JAMA Intern Med. 2016;176(6):816-825. 10
HIGHEST IMPACT: ALL CAUSE MORTALITY Smoking Cardiorespiratory fitness Smoke/ Exercise Lipids Hypertension 11
lipids hypertension cardiorespiratory fitness smoking lipids hypertension Measure me! cardiorespiratory fitness smoking 12
Wen et al Lancet 378, 1244-1253 (2011) T2 DM: SAME CURVE 26% 150 minutes 36% 300 minutes Smith, A.D., Crippa, A., Woodcock, J. et al. Diabetologia (2016). 13
HOW MUCH EXTRA WORK IS THIS GOING TO BE??? AHA SCIENTIFIC STATEMENT ALL HEALTHY ADULTS SHOULD HAVE CRF MEASURED CIRCULATION NOV 30,2016 14
AHA SCIENTIFIC STATEMENT MORE RISK FACTORS: START EARLIER FOR CRF ASSESSMENT, NOT DIAGNOSIS CAD CIRCULATION NOV 30,2016 MAXIMAL HEART RATE in the CHRONIC DISEASE LAB KNOWN CORONARY DISEASE CONGESTIVE HEART FAILURE COPD PERIPHERAL ARTERY DISEASE 15
VO2 Max Testing Athletes only? Gas Exchange CO2:O2 Gold standard Gas Exchange Gold standard VO2 Max Testing Athletes only Max Exercise #2 Submax #3 Calculator #4: easy/fast 16
VO2 Max Testing All Healthy Adults Gas Exchange Gold standard Max Exercise #2 Submax #3 Calculator #4: easy/fast 17
CRF TESTING STEP 1: DECONDITIONED OR UNSURE Duke Activity Status Index DASI DASI Maximum: 9.89 METS (VO2 34) Low to low-moderate fitness 18
STEP 2: CRF VO2 CALCULATOR DASI >9 or younger Higher level of functioning Cardiac Exercise Research Group CERG CRF: STEP 2 CERG VO2 CALCULATOR Need resting and maximum heart rate Vital statistics Exercise volume and frequency 19
HTTPS://WWW.NTNU.EDU/CERG MAX HEART RATE Age Height (cm) Weight (kg) No B-blockers then VO2 MAX Max heart rate Exercise frequency Resting HR Waist (cm) VO2 AND METS CALCULATORS: AMERICAN HEART ASSOCIATION Not a substitute for maximal exercise testing 20
Calculators 3/14/2018 limits pros HR Max: Sex Age Height (cm) Weight (kg) http://www.ntnu.edu/cerg/hrmax 21
Max heart rate More stats Resting heart rate Waist circumference Exercise frequency Exercise intensity VO2 Max 22
VO2 Max Testing Athletes only? Gas Exchange Gold standard Max Exercise #2 Submax #3 Calculator #4: easy/fast 23
CRF ASSESSMENT: ACTIVE Submaximal 6 minute walk test Rockport One Mile walk Test 6 Minute Walk Test 24
ATS 6MWT No definitive parameters Better for treatment assessment <500 meters?poor prognosis 1 MILE WALK TEST (ROCKPORT) PROS Minimal resources Done independently LIMITATIONS Cohort limitations (30-69 yoa) Need accurate measurements Time 25
VO2 MAX TESTING CALCULATOR CERG Underestimates fit Requires subjective data Not substitute for exercise test SUBMAXIMAL 6MWT For advanced deconditioning 1 mile walk test Cohort dependent Multiple measurements Time=GXT Gas Exchange Gold standard VO2 Max Testing Athletes only? Max Exercise #2 Submax #3 Calculator #4: easy/fast 26
MAXIMAL EXERCISE TESTING Not for diagnosis of CAD! Exercise capacity evaluation MAXIMAL EXERCISE TESTING =LAB, NOT OFFICE Known Coronary disease Congestive Heart Failure Peripheral Arterial Disease Chronic Obstructive Pulmonary Disease 27
CRF: ACTIVE MAXIMAL EXERCISE TESTING STEP 1 Administer pre test questionnaire Par-Q+ validated MAXIMAL EXERCISE TESTING: PARQ+ 28
Most frequently encountered contraindications 3/14/2018 FEAR? Cardiac complication 0.8 in 10,000 tests Age range 25-84 Circulation Vol 80, No 4, October 1989 SBP >220 DBP>110 Physical/mental impairment Tachy or brady arrythmias 29
MAXIMAL EXERCISE TESTING Easy Inexpensive Most are walking WHAT ABOUT BIKE? Higher end equipment More difficult to administer for novices 30
VALIDATED TREADMILL PROTOCOLS Bruce protocol Balke Protocol HUNT 3 Fitness Study MOST 31
HUNT 3 Protocol Age Weight Velocity Incline HUNT 3 Warm up 3 minutes Set incline 10% Increase speed.3 mph q 1 minute until exhaustion Test should last 8-12 minutes 32
REFERENCE ARTICLES Reference Articles VO2 Calculator Estimating VO2 peak from a nonexercise prediction model: the HUNT Study, Norway. Nes, BM et al Med Sci Sports Exerc: 2011 Nov;43(11):2024-30. VO2 TESTING IN OFFICE: NO MASK Predicting VO 2peak from Submaximal- and Peak Exercise Models: The HUNT 3 Fitness Study, Norway Henrik and Nes PLOS v11 (1) 2016 33
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